The Manual
Tender Point Survey
Introduction
Widespread musculoskeletal pain has long plagued humankind. It made its appearance in past epochs as lumbago, muscular rheumatism, and fibrositis. Most recently the condition has been labeled as fibromyalgia (FM).
Although etiology and pathophysiology of FM are widely debated, the clinical entity described as FM is estimated to affect from three to six million people in the United States. Historically, there has been great variability in the criteria used for diagnosing FM. The American College of Rheumatology (ACR) conducted a multicenter study published in 1990 that specified two primary criteria that characterized FM: (1) three or more months of widespread pain defined as pain present above and below the waist on the right and left side of the body and along the midline and (2) report of pain at a minimum of 11/18 specified locations (tender points - TPs) throughout the body when palpated with 4 kilograms of digital pressure. These two criteria were selected from a number of variables examined as they were shown to reliably discriminate FM from other musculoskeletal disorders in the multicenter study.
TPs are widely distributed throughout the musculoskeletal system. They are typically located in the muscle bodies, over tendinous insertions and at bony prominences. The anatomic and physiological mechanisms accounting for the presence of TPs have received great attention but explanation for their origin remains unclear.
A number of factors may influence the sensitivity of TPs during an examination: (1) the amount of force applied at the survey site, (2) the number of times (single versus repeated) and method (finger pad, dolorimeter) by which the force is applied, (3) the patient's position, which affects muscle tone and survey site localization. The sequence of site examination may influence the patient's response based on the anchoring effect of sensations experienced at prior survey sites. A standardized examination procedure enhances the reliability of survey site reporting, interobserver reproducibility, the comparability of research studies and the direction of treatment modalities.
The Manual Tender Point Survey (MTPS) outlined in this document describes a technique requiring approximately 5-10 minutes to perform. It is based on the 1990 American College of Rheumatology tender point protocol for FM. This guide will (1) describe the pressure application technique, (2) discuss the precise identification of survey sites, and (3) review the complete Manual Tender Point Survey examination including the standardized examination procedure and patient instructions.
Pressure Application Techniques
The standard procedure for applying pressure in the Manual Tender Point Survey (MTPS) uses the thumb pad of the examiner's dominant hand. This method was adopted because it has been shown to be as reliable as the use of a dolorimeter (strain gauge). Also, it allows the examiner to make use of important tactile cues.
Learning the Feel
of 4 Kilograms
A simple method to learn the feel of 4 kilograms can be developed by using a standard weight scale.
Procedural Guidelines & Patient Instructions
Read
the statement from the scoring sheet:
"Various areas of your body will be examined for pain. Please say 'Yes' or
'No' if there is any pain when I press a specific point."
Explanation
of the scale is also read to the patient:
"I
want you to rate the intensity of the pain on a scale from 0 to 10. 0 is no pain
and 10 is the worst pain that you have ever experienced." ( After testing
survey site 9, the patient should be reminded of the meaning of the pain scale
to reinforce their understanding of the range.)
The 18 survey sites and 3 control sites are examined in the designated numerical order. The figure above shows the general location of survey sites.
Survey Site Identification
Follow the numerical sequence:
1. Forehead (Control)
Patient position: Seated,
head in neutral position.
Examiner position: Front
Procedure:
2 & 3. Occiput
Patient position: Seated,
head loosely flexed forward approximately thirty degrees
Examiner position: Beside and behind
Procedure:
4 & 5. Trapezius
Patient position: Seated,
head in neutral position
Examiner position: Beside and behind
Procedure:
6 & 7. Supraspinatus
Patient position: Seated
Examiner position: Beside and behind
Procedure:
8 & 9. Gluteal
Patient position: Seated
Examiner position: Beside and behind
Procedure:
10 & 11. Low Cervical
Patient position: Seated,
head in neutral position
Examiner position: Beside
Procedure:
12 & 13. Second Rib
Patient position: Seated
Examiner position: Beside
Procedure:
14 & 15. Lateral Epicondyle
Patient position: Seated,
hands on lap
Examiner position: Beside
Procedure:
16. Right Forearm (Control)
Patient position: Seated
Examiner position: Beside
Procedure:
17. Left Thumb (Control)
Patient position: Seated
Examiner position: Beside
Procedure:
18 & 19. Greater Trochanter
Patient position: Lying
on opposite side, leg loosely flexed at the hip and knee
Examiner position: Beside
Procedure:
20 & 21. Knee
Patient position: Lying
on back, feet slightly apart
Examiner position: Beside
Procedure:
Review
Variations Encountered & Their Resolution
Although the standardized protocol for the Manual Tender Point Survey (MTPS) is designed to increase reliability, response to physical examination is inherently liable to variabilities of human perception. Below are listed situations you may encounter in performing the MTPS. They should not significantly confound the MTPS process. Quite the contrary the behavioral characteristics should be noted and the non-verbal communication aspect of the patient's response recognized by the examiner.
Patients will vary in their behavior during the MTPS including their response to the pressure application. Although observing the patient's expressions and body language enhances the overall assessment, the objectivity of these responses is difficult to assess reliability. These responses may be recorded along side the individual survey site scores but are not included in the formal scoring.
On occasion a MTPS may be confounded to the point of being without value. Abandon the survey at least for that visit and note the reason.
Problem
|
Response
|
1. Adipose tissue obscuring landmarks | 1. Base survey site location on scoring sheet outline and directions as closely as possible. |
2. Injury present at survey site area | 2. Note the finding. |
3. Patient remarks, §Thatīs not where I hurt...Ĩ | 3. Examiner responds, §This is not just a search for sore spots. Itīs a survey of specific locations on your body.Ĩ |
4. Patient announces response before you complete your pressure application. | 4. Accept the response and advise the patient to allow the completion of the full pressure application, if possible. |
5. Patient withdraws before you achieve 4 kg. of pressure. | 5. Accept this response and record the patientīs numerical score. Note that full pressure was not applied. |
6. Patient grabs your hand to prevent the pressure application. | 6. Enlist patient cooperation for maintaining relaxed standardized posture. |
7. Assigning a number for pain may be difficult for a patient. | 7. Remind her or him of the scale and say, §Giving your best estimate is sufficient.Ĩ |
Afterward
It is important to note that the diagnosis of FM requires both (1) the presence of widespread pain of at least three months' duration and (2) at least 11/18 positive survey sites. The presence of 11/18 positive sites alone is not sufficient for the diagnosis of FM.
The techniques and guidelines outlined in this booklet are designed to facilitate the following:
The authors are grateful for the advice and criticism of the many people who contributed to the creation of this document. For more information on "The Manual Tender Point Survey" contact:
University of Pittsburgh
Medical Center
Center for Continuing Education in the Health Sciences
522 Nese-Barkan Building
200 Lothrop Street
Pittsburgh, PA 15213
Attn. Linda Levine
Dennis C Turk, PhD
John and Emma Bonica Professor of Anesthesiology and Pain Research
Department of Anesthesiology
University of Washington
Seattle, WA 98195